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92 Economic crisis, health systems and health in Europe: country experience
created in 2009 and was extended, under certain conditions, to people under
25 years of age. In 2012, it was provided to almost 2.1 million households.
Second, the CMU-C and ACS schemes enable people on low incomes to
receive adequate health protection and have allowed an increasing number of
people to benefit from such protection (see section 3.2).
5. Discussion
5.1 Drivers of change
In terms of drivers of change, there has been no direct influence of non-national
actors on health system responses in France, unlike in other countries. 10 The
recent policy recommendations of the European Commission to France
in 2013 focused on labour costs and pension schemes, and contained only
nonspecific recommendations to increase the cost–effectiveness of health care
expenditure. French politicians have publicly shown reluctance to adopt any
such external advice. 11 Furthermore, no crisis-related funds were received from
the International Monetary Fund (IMF), and the actors of the Troika (European
Commission, European Central Bank and the IMF) did not play a role in the
French crisis response. However, such absence of direct external actors will have
to be qualified by long-term processes known as policy learning, transfer or
convergence. Several international actors, such as the European Observatory
on Health Systems and Policies, have been contributing to such developments,
which coexist with transnational initiatives such as direct contacts and
networks, for example, between national agencies or SHI funds. If, in some
cases, these so-called soft-drivers may have been facilitators of change (e.g. the
long-standing European EUnetHTA initiative in fostering a knowledge base
for HTA (European Network for Health Technology Assessment, 2014), or
the English National Health Service pay-for-performance experience, which
inspired the French one), they were, however, not, per se, initiators of change
in the context of the crisis.
5.2 Content and process of change
Hence, there has been no direct influence or use of external agents in the crisis
response, nor a concerted strategy to respond to specific phenomena. The main
trigger for action in France was the fiscal pressure that pre-existed and was
10 At the EU level, such direct influence could have been attempted within the scope of the Stability and Growth Pact
ensuring that Member States adopt appropriate policy responses to correct excessive deficits by implementing the Excessive
Deficit Procedure. This procedure has been in place in France since 2009, and in that year, the European Commission
recommended that France "swiftly implement the planned measures and reforms to contain current expenditure over the
coming years, especially in the areas of health care and local authorities", without further specifications.
11 This was illustrated by representatives of the ruling Socialist Party, who stated that, instead of France following the
recommendations, the European Commission should join French President François Hollande’s fight for "a smart
economic policy, which conciliates thorough budget policy with the preservation of pro-growth investments"
(EurActiv, 2013).